Pop, Rev
Pop, Rev
Pop, Rev
1
ANATOMY OF THE PELVIC
FLOOR
2
External Genital Organ
Vulva
3
Anatomy of the Pelvic Floor
• Boundaries of the perineum
• Posterior: Coccyx
• Blood supply:
4
TRIANGLES
UROGENITAL TRIANGLE
ANAL TRIANGLE
5
Pelvic Outlet
6
Diaphragm
7
Diaphragms
8
Pelvic Diaphragm
• A wide but thin muscular layer of tissue that forms
the inferior border of the abdominopelvic cavity
• Three components :
• Puborectalis - dorsal to the rectum and helps form the sling supporting
the rectum
• Iliococcygeus
• The Coccygeus - a triangular muscle that occupies the area between the
ischial spine and the coccyx.
10
Urogenital Diaphragm
• Also called triangular ligament
14
Normal Support of Pelvic Organs
• Level I (suspension) - the paracolpium (uterosacral
ligaments) suspends the vagina from the lateral pelvic
walls. Fibers of level I extend both vertically and
posteriorly toward the sacrum.
15
PELVIC ORGAN PROLAPSE
16
PELVIC ORGAN PROLAPSE
17
The most frequently cited risk factor for pelvic organ
prolapse is
a. Childbirth
b. Age
c. Obesity
d. Menopause
18
RISK FACTORS
19
Risk Factors
• Possible Associations with Pelvic Organ Prolapse
• Vaginal childbirth
• Prior pelvic surgery Hysterectomy Constipation
• Aging
• Irritable bowel syndrome
• Obesity • Episiotomy
20
Development of Pelvic Floor Dysfunction
21
PATHOPHYSIOLOGY
22
Pathophysiology of POP
• Muscle atrophy
23
SYMPTOMS
24
POP Symptom Categories
Lower urinary tract symptoms Bowel symptoms
Urinary incontinence Constipation
Frequency Straining
Nocturia Incomplete evacuation
Urgency Bowel splinting
Voiding difficulty: Slow stream, Anal incontinence
Incomplete emptying, obstruction
Urinary Splinting
Sexual symptoms
Other symptoms Interference with sexual activity
Pelvic pressure Dyspareunia
Heaviness Decreased sexual desire
Pain
Presence of vaginal bulge/mass
Low back pain
Tampon not retained
Quality of life impacts
25
EVALUATION
26
Proper Evaluation
27
Quantification of POP
Pelvic Organ Prolapse Quantitative, Bump, 1996
28
Maximum prolapse - observed
with a full bladder in the
standing position
29
Support of the bladder neck
Quantification of POP
30
Quantification of POP
(Bayden Walker System)
31
Quantification of POP
Pelvic Organ Prolapse Quantitative, Bump, 1996
32
Quantification of POP
Pelvic Organ Prolapse Quantitative, Bump, 1996
33
POP Q Staging Criteria
Stage 0 Aa, Ap, Ba, Bp = -3cm and C or D ≦ negative (TVL -2cm )
Stage 0 criteria not met and most distal portion is more than 1cm
Stage I
above the level of the hymen [ > -1cm ]
Stage II Leading edge ≦ positive one (+1cm) but ≧ negative one (-1cm)
Stage III Leading edge > +1 cm but < positive (TVL - 2cm)
Stage IV Leading edge ≧ positive (TVL - 2cm)
34
POP - Q System
• stage 0: no prolapse,
35
POP Q Staging Criteria
Stage 0 Aa, Ap, Ba, Bp = -3cm and C or D ≦ negative (TVL -2cm )
Stage 0 criteria not met and most distal portion is more than 1cm
Stage I
above the level of the hymen [ > -1cm ]
Stage II Leading edge ≦ positive one (+1cm) but ≧ negative one (-1cm)
Stage III Leading edge > +1 cm but < positive (TVL - 2cm)
Stage IV Leading edge ≧ positive (TVL - 2cm)
36
Quantification of POP
Pelvic Organ Prolapse Quantitative, Bump, 1996
Aa Ba C
-3 -3 -6
Gh Pb Tvl
6 3 8
Ap Bp D
-3 -3 -6
37
ABOVE
=
NEGATIVE
(-‐)
NUMBER
38
Aa Ba C
-3 -3 -6
Gh Pb Tvl
6 3 8
Ap Bp D
-3 -3 -6
39
POP Q Staging Criteria
Stage 0 Aa, Ap, Ba, Bp = -3cm and C or D ≦ negative (TVL - 2cm )
Stage 0 criteria not met and most distal portion is more than 1cm
Stage I
above the level of the hymen [ > -1cm ]
Stage II Leading edge ≦ positive one (+1cm) but ≧ negative one (-1cm)
Stage III Leading edge > +1 cm but < positive (TVL - 2cm)
Stage IV Leading edge ≧ positive (TVL - 2cm)
Gh Pb Tvl
6 3 8
Ap Bp D
-3 -3 -6
41
POP Q Staging Criteria
Stage 0 Aa, Ap, Ba, Bp = -3cm and C or D ≦ negative (TVL - 2cm )
Stage 0 criteria not met and most distal portion is more than 1cm
Stage I
above the level of the hymen [ > -1cm ]
Stage II Leading edge ≦ positive one (+1cm) but ≧ negative one (-1cm)
Stage III Leading edge > +1 cm but < positive (TVL - 2cm)
Stage IV Leading edge ≧ positive (TVL - 2cm)
Aa Ba C
+4 +3 +2 +1 0 -‐1 -‐2 -‐3 -3 -3 -7
C
or
D Gh Pb Tvl
LESS
than
OR
EQUAL
NEGATIVE
-‐ 6 3 8
(TVL
-‐2
)
cm
C
or
D
(8
-‐2)
NEGATIVE
-‐(6)cm Ap Bp D
+4 +3 +2 +1 0 -‐1 -‐2 -‐3 -‐4 -‐5 -‐6 -‐7 -3 -3 -6
42
Aa Ba C
-3 -3 -5
Gh Pb Tvl
6 3 8
Ap Bp D
-3 -3 -6
43
POP Q Staging Criteria
Stage 0 Aa, Ap, Ba, Bp = -3cm and C or D ≦ negative (TVL - 2cm )
Stage 0 criteria not met and most distal portion is more than 1cm
Stage I
above the level of the hymen [ > -1cm ]
Stage II Leading edge ≦ positive one (+1cm) but ≧ negative one (-1cm)
Stage III Leading edge > +1 cm but < positive (TVL - 2cm)
Stage IV Leading edge ≧ positive (TVL - 2cm)
C
or
D Gh Pb Tvl
LESS
than
OR
EQUAL
Negative
(TVL
-‐2)
cm 6 3 8
C
or
D
(8
-‐2)
Negative
-‐6cm
Ap Bp D
+4 +3 +2 +1 0 -‐1 -‐2 -‐3 -‐4 -‐5 -‐6
-3 -3 -6
44
Aa Ba C
-2 -3 -6
Gh Pb Tvl
6 3 8
Ap Bp D
-3 -3 -6
45
POP Q Staging Criteria
Stage 0 Aa, Ap, Ba, Bp = -3cm and C or D ≦ negative (TVL - 2cm )
Stage 0 criteria not met and most distal portion is more than 1cm
Stage I
above the level of the hymen [ > -1cm ]
Stage II Leading edge ≦ positive one (+1cm) but ≧ negative one (-1cm)
Stage III Leading edge > +1 cm but < positive (TVL - 2cm)
Stage IV Leading edge ≧ positive (TVL - 2cm)
Aa Ba C
-2 -3 -6
+2 +1 0 -‐1 -‐2 -‐3 -‐4 -‐5 -‐6
Gh Pb Tvl
6 3 8
Ap Bp D
-3 -3 -6
46
Aa Ba C
-2 -3 -6
Gh Pb Tvl
6 3 8
Ap Bp D
-3 -3 -6
47
POP Q Staging Criteria
Stage 0 Aa, Ap, Ba, Bp = -3cm and C or D ≦ negative (TVL - 2cm)
Stage 0 criteria not met and most distal portion is more than 1cm
Stage I
above the level of the hymen [ > -1cm ]
Stage II Leading edge ≦ positive one (+1cm) but ≧ negative one (-1cm)
Stage III Leading edge > +1 cm but < positive (TVL - 2cm)
Stage IV Leading edge ≧ positive (TVL - 2cm)
Aa Ba C
-2 -3 -6
Ap Bp D
-3 -3 -6
48
Aa Ba C
-2 -1 -5
Gh Pb Tvl
6 3 8
Ap Bp D
-3 -3 -6
49
POP Q Staging Criteria
Stage 0 Aa, Ap, Ba, Bp = -3cm and C or D ≦ negative (TVL - 2cm)
Stage 0 criteria not met and most distal portion is more than 1cm
Stage I
above the level of the hymen [ > -1cm ]
Stage II Leading edge ≦ positive one (+1cm) but ≧ negative one (-1cm)
Stage III Leading edge > +1 cm but < positive (TVL - 2cm)
Stage IV Leading edge ≧ positive (TVL - 2cm)
Aa Ba C
-2 -1 -5
Ap Bp D
-3 -3 -6
50
Aa Ba C
-2 +1 -5
Gh Pb Tvl
6 3 8
Ap Bp D
-3 -3 -6
51
POP Q Staging Criteria
Stage 0 Aa, Ap, Ba, Bp = -3cm and C or D ≦ negative (TVL - 2cm)
Stage 0 criteria not met and most distal portion is more than 1cm
Stage I
above the level of the hymen [ > -1cm ]
Stage II Leading edge ≦ positive one (+1cm) but ≧ negative one (-1cm)
Stage III Leading edge > +1 cm but < positive (TVL - 2cm)
Stage IV Leading edge ≧ positive (TVL - 2cm)
Aa Ba C
-2 +1 -5
Ap Bp D
-3 -3 -6
52
Aa Ba C
-1 0 -5
Gh Pb Tvl
6 3 8
Ap Bp D
-3 -3 -6
53
POP Q Staging Criteria
Stage 0 Aa, Ap, Ba, Bp = -3cm and C or D ≦ negative (TVL - 2cm)
Stage 0 criteria not met and most distal portion is more than 1cm
Stage I
above the level of the hymen [ > -1cm ]
Stage II Leading edge ≦ positive one (+1cm) but ≧ negative one (-1cm)
Stage III Leading edge > +1 cm but < positive (TVL - 2cm)
Stage IV Leading edge ≧ positive (TVL - 2cm)
Aa Ba C
-1 0 -5
Ap Bp D
-3 -3 -6
54
Aa Ba C
+2 +4 +5
Gh Pb Tvl
6 3 8
Ap Bp D
-3 -3 -2
55
POP Q Staging Criteria
Stage 0 Aa, Ap, Ba, Bp = -3cm and C or D ≦ negative (TVL - 2cm)
Stage 0 criteria not met and most distal portion is more than 1cm
Stage I
above the level of the hymen [ > -1cm ]
Stage II Leading edge ≦ positive one (+1cm) but ≧ negative one (-1cm)
Stage III Leading edge > +1 cm but < positive (TVL - 2cm)
Stage IV Leading edge ≧ positive (TVL - 2cm)
Ap Bp D
-3 -3 -2
56
Aa Ba C
+2 +4 +6
Gh Pb Tvl
6 3 8
Ap Bp D
+2 +2 +2
57
POP Q Staging Criteria
Stage 0 Aa, Ap, Ba, Bp = -3cm and C or D ≦ negative (TVL - 2cm)
Stage 0 criteria not met and most distal portion is more than 1cm
Stage I
above the level of the hymen [ > -1cm ]
Stage II Leading edge ≦ positive one (+1cm) but ≧ negative one (-1cm)
Stage III Leading edge > +1 cm but < positive (TVL - 2cm)
Stage IV Leading edge ≧ positive (TVL - 2cm)
Aa Ba C
+6 +5 +4 +3 +2 +1 0 -‐1 -‐2 -‐3 +2 +4 +6
Gh Pb Tvl
MORE
THAN
OR
EQUAL
to
POSITIVE
(TVL
-‐2
)
CM 6 3 8
8
-‐2
Equals
POSITIVE
6cm
Ap Bp D
+2 +2 +2
58
POP CLASSIFICATION SYSTEMS
59
QUESTION
In POP Q system all of the measurements are
performed while the patient strains (bears down)
EXCEPT
A. TVL
B. GH
C. Point D
D. Point Aa
E. Point Bp
60
If surgical management of
prolapse is being
considered, the physician
may want to perform a
preoperative prolapse
reduction standing stress
test to evaluate for stress
urinary .
61
BLADDER & URETHRA
ANATOMY & FUNCTION
62
Bladder & Urethra
Anatomy & Function
• Anatomically, the exact border between the bladder and
urethra is difficult to determine.
63
Intravesical pressure depends on the following:
64
Bladder & Urethra
Anatomy & Function
• For continence to be present, the UCP must be higher
than the bladder pressure.
66
Topography of Urethral and
Paraurethral structures
67
Bladder & Urethra
Anatomy & Function
• At rest, the urethra is supported by its attachment to
the arcus tendineus fasciae pelvis and the tone of the
pelvic diaphragm muscles.
69
Normal Support of Pelvic Organs
• Level I (suspension) - the paracolpium (uterosacral
ligaments) suspends the vagina from the lateral pelvic
walls. Fibers of level I extend both vertically and
posteriorly toward the sacrum.
70
INNERVATION OF THE
BLADDER & URETHRA
71
INNERVATION OF
BLADDER AND URETHRA
72
INNERVATION OF
BLADDER AND URETHRA
SYMPATHETIC PARASYMPATHETIC
Neurotransmitter Norepinephrine Achetylcholine
Receptor alpha, beta Muscarinic (M3)
Detrussor Muscle
Relaxation Contraction
Bladder
Striated Muscle
External Urethral Contraction Relaxation
sphincter
Net effet Prevent Micturition Voiding
73
PHYSIOLOGY OF
MICTURITION
74
NEUROLOGIC CONTROL
OF MICTURITION
75
CNS FEEDBACK LOOPS
76
Physiology of Micturition
• Bladder detrusor contractility is stimulated by the activity of the
parasympathetic nervous system, mediated primarily through the
neurotransmitter acetylcholine.
77
PHYSIOLOGY OF MICTURITION
• The first loop (loop I) involves a circuit from the cerebral cortex to
the brain stem, which inhibits micturition by modifying sensory
stimuli emanating from loop II.
• Loop II, which originates in the sacral micturition center (S2 through
S4) and the detrusor muscle wall itself, represents sensory fibers to
the brain stem, where modulation of the stimuli by loop I takes place.
• Loop III involves sensory flow from the bladder wall to the sacral
micturition center with returning motor fibers to the urethral
sphincter striated muscle, which allows the voluntary relaxation of
the urethral sphincter as the detrusor contracts.
• Loop IV originates in the frontal lobe of the cerebral cortex and runs
to the sacral micturition center and then to the urethral striated
muscle, allowing urethral voluntary muscles to relax, thus leading to
the initiation of voiding.
78
DIAGNOSTIC
PROCEDURES
79
Diagnostic Procedures
• Urinalysis and Culture
• Residual Urine
• Bladder diary
• Office Cystometrics
• Urodynamics
• Cystourethroscopy or Cystoscopy
80
Diagnostic Procedures
Urinalysis and Culture
81
Diagnostic Procedures
Test for Residual Urine
Bladder diary
83
Diagnostic Procedures
Urodynamics ( Cystometry)
• measures bladder pressure during the filling phase of the
micturition cycle.
• First urge to void, normal desire to void, and bladder
capacity are noted
84
Diagnostic Procedures
Office Cystometry
85
Diagnostic Procedures
Office Cystometry
• with catheter attached to a
50-ml syringe w/o plunger
held 15cm above
symphysis pubis
86
Diagnostic Procedures
Office Cystometry
•NORMAL
water level in the syringe
CONSTANT
• OAB
water level in the syringe
(listening to running water,
washing of hands)
FLUCTUATION
87
Diagnostic Procedures
Cough Stress Test
• Instill 250 to 300 ml of saline
• Once max. bladder capacity is
reachedà remove catheter
• à STRESS TEST (provocative
measures: coughing, heel
bouncing)
89
Diagnostic Procedures
Urodynamics ( Multichannel Recorder - ideal )
• For greatest accuracy, these should be measured with the woman
in the sitting position as well as standing, at rest, and with
straining.
• To use a multichannel recorder that permits pressure
determinations
• at two points within the urethra (proximal and midpoint to distal),
one within the bladder,
• one intraabdominally as recorded by an intrarectal sensor or by a
sensor within the vagina if the vagina is in a relatively normal
position (not prolapsed)
• Indicate intrinsic sphincter deficiency.
• Abdominal Leak Point Pressure (ALPP) - less than 60 cm H2O
• Maximal urethral closure pressure (MUCP) - below 20 cm H2O
90
Diagnostic Procedure
• Cystourethroscopy (
Cystoscopy )
• allows visualization of
the urethra, bladder,
and ureteral orifices in
an office setting
91
Urethral hypermobility
• Q-tip test
92
RISK FACTORS
URINARY INCONTINECE
93
FACTORS INDEPENDENTLY ASSOCIATED
WITH INCONTINENCE IN WOMEN
94
SYMPTOMS
95
Stress Urinary Incontinence
(SUI)
96
Over
Active
Bladder
Syndrome
• Urgency, with or without urge incontinence,
usually with frequency and nocturia
97
Urge Incontinence (UI)
98
Typical Symptom Differences in
Stress and Urge Incontinence
Symptom SUI UI
Leakage with exertion, cough, sneeze, activity Yes No
99
Detrusor Overactivity
• Previous terms: detrusor dyssynergia, unstable bladder, or
detrussor instability
100
MANAGEMENT
STRESS INCONTINENCE
1. Conservative
2. Surgical
101
Stress Urinary Incontinence
Methods of Pelvic Muscle ( Levator Ani and
Pubococcygeal ) Strengthening
• Kegel exercises
• Biofeedback
102
Methods of Pelvic Muscle ( Levator
And and Pubococcygeal ) Strengthening
103
Methods of Pelvic Muscle ( Levator
And and Pubococcygeal ) Strengthening
• Biofeedback
• Electrical
stimulation
105
Incontince Pessary
106
Incontinence Pessary
• An incontinence pessary is a silicone ring device
with a knob placed in the vagina, with the goal of
stabilizing the urethra to eliminate hypermobility
and increase urethral pressure during increases in
intraabdominal pressure.
107
Effects of Other Modalities
108
Drugs with Possible Effects
on the Lower Urinary Tract
• Estrogen orally, Xanthines, Neuroleptics , anti
hypertensives ( All causes incontinence )
• Retropubic urethropexy
111
Burch
Procedure
• Modification
of
the
suprapubic
bladder
neck
suspension
by
suspending
the
vaginal
wall
to
Cooper’s
ligament,
now
referred
to
as
a
Burch
colposuspension
or
Burch
procedure
112
Mid Urethral Sling
Tension-free vaginal tape (TVT) permanent
sling with Prolene mesh placed midurethrally,
without the need for fixation . For stress
incontinence.
113
MANAGEMENT
OVERACTIVE BLADDER
1. Conservative
2. Surgical
114
Over Active Bladder (OAB)
• Behavioral is the first line treatment
• Bladder training
115
Over Active Bladder (OAB)
• Pharmacologic
116
Medications for Overactive Bladder
Drug Dosage
5mg BID,TID,QID
Oxybutynin 5 to 30 mg daily
1 or 2 mg BID
Tolterodine 4mg daily
Solifenacin 5 or 10 mg daily
Mirabergron 25 to 50 mg daily
117
Treatment
algorithm for
urge
incontinence
118
Over Active Bladder (OAB)
Neuromodulation
• beneficial for women with refractory symptoms (failed
behavioral treatments and medications over roughly 3
months).
119
Effective Treatment Options for Women with
Urinary Incontinence by Type of Incontinence
Treatment Option SUI UI
Anticholinergic drugs
Pharmacologic (antimuscarinic)
Beta agonist
121
CONSERVATIVE
• mild or asymptomatic uterine prolapse - no needed
treatment or with pelvic floor muscle strengthening
122
PESSARY - EFFECTS
• It reduced symptoms of POP, • relieved urinary symptoms
such as
• general symptoms of a
vaginal bulge.
• bowel evacuation in 28%,
• relieved urinary symptoms
such as • fecal urgency in 23%
123
PESSARY - COMPLICATION
• Rare with proper use
• Vaginal infections,
• Bleeding,
• Discomfort,
• Pessary incarceration
124
Surgical
• Common surgical options to treat uterovaginal prolapse include
vaginal hysterectomy with vault suspension to the uterosacral or
sacrospinous ligaments, abdominal (open, laparoscopic, or
robotic)
125
126
127
Surgical
• Manchester procedures
• Colpocleisis
128
Surgical
• Goodal Power Modification of the Le Fort operation
129
Le Fort Procedure.
F, Appearance of vagina a er
procedure is completed but before
perineorrhaphy is performed.
130
Goodall-Power modification of Le
Fort operation.
E, Appearance at completion of
procedure 131
132
CLASSIC ANTERIOR COLPORRHAPY
A. The initial midline anterior vaginal wall incision is
demonstrated
133
Rectocoele
• Management
• None operative
134
REPAIR OF RECTOCOELE
135
136
137
A, Appearance of enterocele
sac with vaginal wall
reflected.
B, Appearance of open
enterocele sac with sac neck
identified.
C, Placing of purse-string
suture at the neck of the
enterocele sac.
D, Excision of enterocele
sac. 138
End of Lecture
139